BILL ANALYSIS Ó
SB 491
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Date of Hearing: August 21, 2013
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Mike Gatto, Chair
SB 491 (Hernández) - As Amended: August 14, 2013
Policy Committee: Business and
Professions Vote: 8-2
Urgency: No State Mandated Local Program:
Yes Reimbursable: No
SUMMARY
This bill allows nurse practitioners (NPs) who meet certain
criteria to practice independently of physician supervision (for
purposes of this analysis, an "independent NP"). Specifically,
this bill:
1)Requires an independent NP to have first practiced under the
supervision of a physician for 4,160 hours and be practicing
in a clinic, health facility, county medical facility,
accountable care organization (ACO), or a group practice.
Also requires an independent NP to maintain professional
liability insurance appropriate to the practice setting.
2)Requires an independent NP to refer patients to another health
care provider if a situation or condition of the patient is
beyond the NP's education or training.
3)Establishes the scope of practice for an independent NP, which
generally aligns with existing law, regulation, and practice
regarding scope of NPs working subject to standardized
procedures and protocols. This bill includes the following
elements under an independent NP's scope: ordering durable
medical equipment, prescribing drugs, establishing diagnoses,
referring patients, performing procedures that are consistent
with their training, and delegating tasks to medical
assistants, among others.
4)Requires the Board of Registered Nursing (BRN) to adopt
regulations by July 1, 2015, establishing the means of
documenting completion of the new requirements.
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FISCAL EFFECT
Costs would accrue to the fee-supported Board of Registered
Nursing Professions and Vocations Fund.
1)One-time costs as follows:
a) Costs to issue regulations and potentially modify
existing regulations, and develop verification processes,
procedures, and documents, likely exceeding $200,000.
b) Costs of around $100,000 over the first two years to
certify existing NPs who meet the criteria. BRN projects
nearly all NPs would seek the additional independent
certification.
c) Costs to update IT systems of $20,000.
1)Annual costs of at least $120,000 to BRN for ongoing
regulation of independent NPs, including licensing,
complaints, and enforcement.
2)Unknown potential costs related to enforcement cases, if it is
more workload-intensive for the BRN to establish whether
appropriate care was provided according to a nurse's scope of
practice, without comparing the treatment with standardized
procedures and protocols. Additional expert review may be
necessary to establish standard of care, which could raise
enforcement costs.
3)The certification process for independent NPs creates
additional workload not supported by new fee authority. The
independent NP certification process could potentially be
combined with a renewal of NP certification to minimize costs,
but this bill does create a higher level of ongoing workload
with respect to certification.
COMMENTS
1)Rationale . This bill seeks to expand the role of NPs
consistent with best practices as identified by the Institute
of Medicine. The author believes this bill will improve
access to care and improve the performance of the health care
system.
2)NPs in California . The BRN licenses about 400,000 registered
nurses (RNs) in the state, and of these, about 18,000 are
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certified as advanced practice RNs, or NPs. NPs are required
to have a Master's degree and have additional preparation and
skills in physical diagnosis, psycho-social assessment, and
management of primary health care needs beyond minimum
requirements for RNs.
About 12,000 of California's 18,000 NPs also have furnishing
numbers issued by the BRN, which allows them to order or
furnish drugs and devices to patients using approved
standardized procedures. NPs must complete an approved
advanced pharmacology course in order to qualify for a
furnishing number. Physician supervision is required and the
physician must be available, at least by telephonic means, at
the time the NP examines the patient. Only furnishing NPs are
required to be supervised by a physician. An NP with a
furnishing number may obtain a Drug Enforcement Administration
(DEA) registration number to order controlled substances as
needed for patient care.
The NP scope of practice is currently determined by
standardized procedures, which are the legal mechanism for NPs
to perform functions which would otherwise be considered the
practice of medicine. Standardized procedures are policies
and protocols developed by a health facility or organized
health care system, with input from administrators and health
professionals, which establish parameters for medical care.
3)IOM Report . The Institute of Medicine (IOM) of the National
Academies recently reviewed nursing education and scope of
practice with a focus on the future of nursing. The IOM
concluded that advanced practice RNs (NPs in California)
should be able to practice to the full extent of their
education and training, and recommended states reform
scope-of-practice rules to remove restrictions on advanced
practice RNs (NPs). The IOM report states, "No studies suggest
that advanced practice RNs (NPs) are less able than physicians
to deliver care that is safe, effective, and efficient, or
that care is better in states with more restrictive scope of
practice regulations for advanced practice RNs (NPs). In fact,
evidence shows that nurses provide quality care to patients,
including preventing medication errors, reducing or
eliminating infections, and easing the transition patients
make from hospital to home."
4)Recent Amendments . A previous version of this bill also
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allowed NPs to practice independently after three years of
supervision, without restricting those NPs to practicing in
specified clinic or group practice settings. A recent
amendment removed this "second pathway" to independent NP
certification. Thus, any NP who practiced pursuant to this
bill would only be able to do so in the settings specified.
5)Support . Nursing groups; health facilities including the
California Primary Care Association, California Hospital
Association, and University of California; the California
Association of Physician Groups; the BRN; and some labor
groups are among numerous supporters of this bill. Supporters
believe this bill will increase Californians' access to care,
reduce paperwork burdens, and promote high-quality primary
health care.
6)Opposition . The California Medical Association, California
Association of Family Physicians, Osteopathic Physicians and
Surgeons of California, and numerous other physician
associations, as well as some labor groups, the Consumer
Attorneys of California, believe this bill compromises patient
safety. The physician groups emphasize collaborative care
provided by a physician-led team is ideal. They indicate
requirements for standardized protocols and physician review
are in place to ensure that patient care includes the
involvement and oversight of a physician who is substantially
more qualified and experienced to oversee patient care, both
in depth and in years of education and training, than a nurse
practitioner practicing alone.
7)Related Legislation . SB 492 (Hernandez) and SB 493
(Hernandez) expand scope of practice for optometrists and
pharmacists, respectively. SB 492 is pending in Assembly
Business and Professions, and SB 493 is pending in this
committee.
Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081